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  • NCP Asthma

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    Ella Neiza Angeles
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    The patient presented with wheezing and difficulty breathing. The nurse's assessment found the patient using accessory muscles and unable to lie down. The nurse planned to elevate the patient's head, encourage pursed lip breathing, and administer ordered corticosteroids. After 8 hours, the interventions helped the patient maintain an optimal breathing pattern.

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    NCP_ASTHMA

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    The patient presented with wheezing and difficulty breathing. The nurse's assessment found the patient using accessory muscles and unable to lie down. The nurse planned to elevate the patient's head, encourage pursed lip breathing, and administer ordered corticosteroids. After 8 hours, the interventions helped the patient maintain an optimal breathing pattern.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    Download as pdf or txt
    51 views3 pages

    NCP Asthma

    Uploaded by

    Ella Neiza Angeles
    The patient presented with wheezing and difficulty breathing. The nurse's assessment found the patient using accessory muscles and unable to lie down. The nurse planned to elevate the patient's head, encourage pursed lip breathing, and administer ordered corticosteroids. After 8 hours, the interventions helped the patient maintain an optimal breathing pattern.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    of 3

    PLANNING

    NURSING
    ASSESSMENT OBJECTIVE OF IMPLEMENTATION EVALUATION
    DIAGNOSIS INTERVENTION RATIONALE
    CARE
    Independent Nursing
    Subjective Cues: Ineffective After 8 hours of Action
    Breathing Pattern nursing interventions
    The patient’s wife evidenced by his the patient will be Maintain head of bed This promotes Patient’s head was Patients was able
    drove him to the clinic wheezing, able to; elevated. maximum lung elevated to maintained
    when his wheezing abnormal expansion and assists optimal breathing
    was unresponsive to respiration rate and Patient will maintain in breathing. pattern.
    fluticasone. usage of accessory optimal breathing
    muscles pattern, as evidenced Encourage client to Pursed lip breathing Purse lip breathing
    by relaxed breathing, use pursed-lip improves breathing exercises were
    normal respiratory breathing for patterns by moving encouraged
    Objective Cues: rate or pattern, and exhalation. old air out of the lungs
    absence of dyspnea. and allowing for new
    The patient was unable to
    lie down, and he began to air to enter the lungs.
    use accessory muscles to
    breathe. Dependent Nursing
    Actions
    Vital Signs: Short-acting beta2- Corticosteroids
    Administer agonists are
    Corticosteroids medicines were
    Blood pressure 152/84 bronchodilators. They administered
    mm Hg medication as relax the muscles
    ordered lining the airways that
    Pulse rate 124 carry air to the lungs;
    beats/min treatment of choice for
    acute exacerbation of
    Respiratory rate 42 asthma.
    breaths/min

    Temperature 38.4° C
    Oxygen Saturation 89
    % (pulse oximeter)

    References:

    Black, J. M., & Hawks, J. H. (2009). Medical-surgical nursing: Clinical management for positive outcomes (Vol. 1). A. M. Keene (Ed.). Saunders Elsevier.
    Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2016). Nurse’s pocket guide: Diagnoses, prioritized interventions, and rationales. FA Davis.
    Doenges et.al. (2019). Nurse’s Pocket Guide: Diagnoses, Prioritized, Interventions and rationales (Fifteenth ed.). F.A. Davis Company.
    Potter, P., & Perry, A.G. (2017). Fundamentals of Nursing (19 ed., Vol. 1). Elsevier.
    th

    Gulanick, M., & Myers, J. L. (2016). Nursing Care Plans: Diagnoses, Interventions, and Outcomes. Elsevier Health Sciences

    PLANNING
    NURSING
    ASSESSMENT OBJECTIVE IMPLEMENTATION EVALUATION
    DIAGNOSIS INTERVENTION RATIONALE
    OF CARE
    Independent Nursing
    Subjective Cues: Action

    The patient’s wife drove Dependent Nursing .


    him to the clinic when his Actions
    wheezing was
    unresponsive to
    fluticasone.
    Objective Cues:

    The patient was unable to


    lie down, and he began to
    use accessory muscles to
    breathe.

    Vital Signs:

    Blood pressure 152/84


    mm Hg

    Pulse rate 124 beats/min

    Respiratory rate 42
    breaths/min

    Temperature 38.4° C

    Oxygen Saturation 89 %
    (pulse oximeter

    References:

    Black, J. M., & Hawks, J. H. (2009). Medical-surgical nursing: Clinical management for positive outcomes (Vol. 1). A. M. Keene (Ed.). Saunders Elsevier.
    Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2016). Nurse’s pocket guide: Diagnoses, prioritized interventions, and rationales. FA Davis.
    Doenges et.al. (2019). Nurse’s Pocket Guide: Diagnoses, Prioritized, Interventions and rationales (Fifteenth ed.). F.A. Davis Company.
    Potter, P., & Perry, A.G. (2017). Fundamentals of Nursing (19 ed., Vol. 1). Elsevier.
    th

    Gulanick, M., & Myers, J. L. (2016). Nursing Care Plans: Diagnoses, Interventions, and Outcomes. Elsevier Health Sciences

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